Deck 60: Nursing Management Stroke

Question 1

The nurse is caring for a client who had a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which of the following interventions should be included in the care plan?

A)Applying compression gradient stockings
B)Assisting to dangle on edge of bed and assess for dizziness
C)Encouraging client to cough and deep breathe every 4 hours
D)Inserting an oropharyngeal airway to prevent airway obstruction

Answer 1

Applying compression gradient stockings

Question 2

The health care provider prescribes clopidogrel for a client with cerebral atherosclerosis. Which of the following information should the nurse include when teaching the client about the new medication?

A)Monitor and record the blood pressure daily.
B)Call the health care provider if stools are tarry.
C)It will dissolve clots in the cerebral arteries.
D)It will reduce cerebral artery plaque formation.

Answer 2

Call the health care provider if stools are tarry.

Question 3

The nurse is caring for a client who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. Which of the following actions should the nurse anticipate as treatment for this client?

A)Prophylactic clipping of cerebral aneurysms
B)Heparin via continuous intravenous infusion
C)Oral administration of low dose Aspirin therapy
D)Therapy with tissue plasminogen activator (tPA)

Answer 3

Oral administration of low dose Aspirin therapy

Question 4

Several weeks after a stroke, a client has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which of the following nursing interventions will be best to include in the plan of care?

A)Limit fluid intake to 1 200 mL daily to reduce urine volume.
B)Assist the client onto the bedside commode every 2 hours.
C)Perform intermittent catheterization after each voiding to check for residual urine.
D)Use an external "condom" catheter to protect the skin and prevent embarrassment.

Question 5

The nurse is caring for a client with a left-sided brain stroke who suddenly bursts into tears when family members visit. Which of the following actions should the nurse implement?

A)Use a calm voice to ask the client to stop the crying behaviour.
B)Explain to the family that depression is normal following a stroke.
C)Have the family members leave the client alone for a few minutes.
D)Teach the family that emotional outbursts are common after strokes.

Question 6

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to insufficient dietary intake (secondary to impaired self-feeding ability) for a client with right-sided hemiplegia. Which of the following interventionsshould be included in the plan of care?

A)Provide a wide variety of food choices.
B)Provide oral care before and after meals.
C)Assist the client to eat with the left hand.
D)Teach the client the "chin-tuck" technique.

Question 7

The nurse is admitting a client who had a stroke and is experiencing right-sided arm and leg paralysis and facial drooping on the right side. Which of the following clinical manifestations should the nurse expect to find?

A)Impulsive behaviour
B)Right-sided neglect
C)Hyperactive left-sided reflexes
D)Difficulty in understanding commands

Question 8

The nurse is caring for a client who has had a stroke and has a new prescription to attempt oral feedings. After assessing the client's gag reflex, which of the following actions should the nurse do next?

A)Order a varied puréed diet.
B)Assess the client's appetite.
C)Assist the client into a chair.
D)Offer the client a sip of juice.

Question 9

A client who has a history of a transient ischemic attack (TIA) has an order for Aspirin 160 mg daily. When the nurse is administering the medications, the client says, "I don't need the Aspirin today. I don't have any aches or pains." Which of the followingactions should the nurse take?

A)Document that the Aspirin was refused by the client.
B)Tell the client that the Aspirin is used to prevent aches.
C)Explain that the Aspirin is ordered to decrease stroke risk.
D)Call the health care provider to clarify the medication order.

Question 10

The nurse receives a verbal report that a client has an occlusion of the left posterior cerebral artery. Which of the following findings should the nurse anticipate?

A)Dysphasia
B)Confusion
C)Visual deficits
D)Poor judgement

Question 11

The nurse is admitting a client with left-sided homonymous hemianopsia resulting from a stroke. Which of the following interventions should the nurse include in the plan of care during the acute period of the stroke?

A)Apply an eye patch to the left eye.
B)Approach the client from the left side.
C)Place objects needed for activities of daily living on the client's right side.
D)Reassure the client that the visual deficit will resolve as the stroke progresses.

Question 12

The nurse is caring for a client who had a stroke affecting the right hemisphere of the brain. Which of the following nursing diagnoses is appropriate based on knowledge of the effects of right brain damage?

A)Impaired physical mobility related to decrease in muscle control (right hemiplegia).
B)Risk for injury as evidenced by alteration in cognitive functioning
C)Impaired verbal communication related to environmental barrier (impaired speech)
D)Ineffective coping related to insufficient sense of control (depression and distress about disability).

Question 13

The nurse is assessing a client with a possible stroke and finds that the client's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these prescriptions by the health care provider should the nurse question?

A)Infuse normal saline at 75 mL/hour.
B)Keep head of bed elevated at least 30 degrees.
C)Administer tissue plasminogen activator (tPA) per protocol.
D)Titrate labetalol drip to keep BP less than 140/90 mm Hg.

Question 14

The nurse obtains all of the following information about a client in the clinic. When developing a plan to decrease stroke risk, which of the following risk factors is most important for the nurse to address?

A)The client has a daily glass of wine to relax.
B)The client is 13 kg above the ideal weight.
C)The client works at a desk and relaxes by watching television.
D)The client's blood pressure is usually about 180/90 mm Hg.

Question 15

The nurse is caring for a client who has right-sided weakness after a stroke and is attempting to use the left hand for feeding and other activities. The client's partner insists on feeding and dressing him, telling the nurse, "I just don't like to seehimstruggle." Which of the following nursing diagnoses is most appropriate for the client?

A)Situational low self-esteem related to pattern of helplessness
B)Interrupted family processes related to shift in family roles (effects of illness of a family member)
C)Disabled family coping related to differing coping styles between support person and client
D)Impaired nutrition: less than body requirements related to insufficient dietary intake (hemiplegia and aphasia)

Question 16

The health care provider recommends a carotid endarterectomy for a client with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The client asks the nurse to describe the procedure. Which of the following responses by the nurseisappropriate?

A)"The carotid endarterectomy involves surgical removal of plaque from an artery in the neck."
B)"The diseased portion of the artery in the brain is removed and replaced with a synthetic graft."
C)"A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."
D)"A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

Question 17

The nurse identifies the nursing diagnosis of impaired verbal communication for a client with expressive aphasia. Which of the following actions should the nurse implement to help the client communicate?

A)Have the client practice facial and tongue exercises.
B)Ask simple questions that the client can answer with "yes" or "no."
C)Develop a list of words that the client can read and practice reciting.
D)Prevent embarrassing the client by changing the subject if the client does not respond.

Question 18

A client is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the client about

A)Alteplase (tPA).
B)Aspirin.
C)Warfarin.
D)Nimodipine.

Question 19

Aclient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Which of the following procedures should the nurse anticipate?

A)Surgical endarterectomy
B)Transluminal angioplasty
C)Intravenous heparin administration
D)Tissue plasminogen activator (tPA) infusion

Question 20

The nurse is caring for a client who has recently had a stroke. When reviewing the clients' laboratory report, which of the following results should the nurse report the health care provider?

A)PaCO? 51 mm Hg
B)pH 7.41
C)PaO? 96 mm Hg
D) WBC 9.2 * 10?/L

Question 21

The nurse is caring for a client who has had a subarachnoid hemorrhage and is being cared for in the intensive care unit. Which of the following information about vasospasms should the nurse be aware of when planning care?

A)The client's blood pressure is 100/50 mm Hg.
B)Endothelin will subside the vasospasm
C)The cerebro-spinal fluid (CSF) report shows red blood cells (RBCs).
D)Peak time for occurrence is 7-10 days post bleed.

Question 22

The nurse is teaching a client's family about immediate stroke care. Which of the following information should the nurse include in teaching plan?

A)Hypotension post stroke is normal.
B)Antihypertensive medication is administered if the mean arterial pressure is >130 mm Hg.
C)Diuretic ordered in the systolic BP is >160 mm Hg.
D)Withholding medications until the degree of dysphasia is known.

Question 23

The nurse is receiving a change-of-shift report. Which of the following clients should the nurse see first?

A)A client with right-sided weakness who has an infusion of tPA prescribed
B)A client who has atrial fibrillation and a new prescription for warfarin
C)A client who experienced a transient ischemic attack yesterday who has a dose of Aspirin due
D)A client with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled

Question 24

The nurse is caring for a client who had a stroke and is in the acute phase of care. Which of the following systems is priority?

A)Neurological system
B)Respiratory system
C)Gastro-intestinal system
D)Genito-urinary system

Question 25

The nurse is admitting a client who began experiencing right-sided arm and leg weakness to the emergency department. In which order should the nurse implement these actions included in the stroke protocol? (Select all that apply.)

A)Obtain CT scan without contrast.
B)Infuse tissue plasminogen activator (tPA).
C)Administer oxygen to keep O2 saturation >95%.
D)Use National Institute of Health Stroke Scale to assess client.

Question 26

The nurse is caring for a client with sudden-onset right-sided weakness who has a CT scan and is diagnosed with an intracerebral hemorrhage. Which of the following information about the client is most important to communicate to the health care provider?

A)The client's speech is difficult to understand.
B)The client's blood pressure is 144/90 mm Hg.
C)The client takes a diuretic because of a history of hypertension.
D)The client has atrial fibrillation and takes warfarin.

Question 27

The nurse is admitting a client with right-sided weakness that started 90 minutes earlier to the emergency department and all these diagnostic tests are prescribed. Which of the following tests should be done first?

A)Electrocardiogram (ECG)
B)Complete blood count (CBC)
C)Chest radiograph (chest x-ray)
D)Noncontrast computed tomography (CT) scan

Question 28

The nurse is caring for a client with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the client?

A)Impaired physical mobility related to decrease in muscle strength
B)Risk for injury as evidenced by alteration in cognitive function
C)Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobilty)
D)Risk for aspiration as evidenced by impaired ability to swallow

Question 29

The nurse is admitting a client with left-sided hemiparesis who has arrived by ambulance to the emergency department. Which of the following actions should the nurse take first?

A)Check the respiratory rate.
B)Monitor the blood pressure.
C)Send the client for a CT scan.
D)Obtain the Glasgow Coma Scale score.